Complications of DM

Question 1

assess vascular risk

Answer 1

target is <140/80mmHg (or 125/75 with renal disease - increased creatinine, microalbuminuria or dipstick proteinuria)
BP control is critical for preventing macrovascular disease and decreasing mortality

Question 2

look for complications

Answer 2

check injection sites for infections or lipohypertrophy

advise on rotating sites of injection if present

Question 3

vascular disease

Answer 3

chief cause of death
MI is 4-fold commoner in DM and more likely to be silent
stroke is twice as common
women are at high risk, because DM removes the protection that females get from their gender
address other risk factors - smoking, HTN, diet
suggest a statin for all, even if no overt IHD, vascular disease or microalbuminuria

Question 4

nephropathy

Answer 4

micoralbuminuria when dipstick is negative for protein but the albumin:creatinine ratio is >3mg/mmol reflecting early renal disease and increased vascular risk
if >3mg/mmol inhibit the renin-angiotensin system with ACE inhibitors even if normal BP protects the kidneys
spironolactone (K sparing diuretic) may also help

Question 5

diabetic retinopathy

Answer 5

blindness is preventable
annual retinal screening mandatory
pre-symptomatic screening allows laser photocoagulation to be used - aims to stop production of angiogenic factors from the ischaemic retina
indications: maculopathy or proliferative retinopathy

Question 6

background retinopathy

Answer 6

microaneurysms (dots) 
haemorrhages (blots)
hard exudates (lipid deposits)

refer if near the macula eg for intravitreal triamcinolone (steroid injection)

Question 7

pre-proliferative retinopathy

Answer 7

cotton wool spots (infarcts)
haemorrhages
venous bleeding

these are signs of retinal ischaemia. refer to specialist

Question 8

proliferative retinopathy

Answer 8

new vessels form

needs urgent referral

Question 9

maculopathy

Answer 9

hard to see in early stages
suspect if acuity decreases
prompt laser, intravitreal steroids or anti-angiogenic agents may be needed in macular oedema

Question 10

pathogenesis maculopathy

Answer 10

capillary endothelial damage–>vascular leak–>microaneurysms–>capillary occlusion–>local hypoxia and ischaemia–>new vessel formation
this is triggered by high retinal blood flow caused by hyperglycaemia, causing cap pericyte damage
microvascular occlusion causes cotton-wool spots (infarcts)
new vessels form on the disc, or ischaemic areas, proliferate, bleed, fibrose and can detach the retina

Question 11

cataracts

Answer 11

may be juvenile ‘snowflake’ form or senile - which occur earlier in diabetic subjects
osmotic changes in the lens induced in acute hyperglycaemia. reversed with normoglycaemia

Question 12

rubeosis iridis

Answer 12

new vessels form on the iris

may lead to glaucoma

Question 13

feet

Answer 13

amputations are common and preventable with good foot care

examine feet regularly

Question 14

neuropathy

Answer 14

decreased sensation in stocking distribution
absent ankle jerks
neuropathic deformity: pes cavus, claw toes, loss of transverse arch, rocker-bottom sole

Question 15

ischaemia

Answer 15

if pulses cannot be felt use doppler

any evidence of neuropathy or vascular disease raises risk of ulceration

Question 16

ulceration

Answer 16

typically a painless, punched out ulcer in area if thick callus with or without added infection

Question 17

mononeuritis multiplex

Answer 17

type or peripheral neuropathy with damage to two or more different nerve areas eg III & VI CN
Rx is hard. if severe, immunosuppression may help (corticosteroids, IV immunoglobulin, ciclosporin)

Question 18

amyotrophy

Answer 18

painful wasting of quadriceps and other pelvifemoral muscles

Question 19

autonomic neuropathy

Answer 19

postural BP drop
decreased cerebrovascular autoregulation
loss of respiratory sinus arrhthymia (vagal neuropathy)
gastroparesis
ED
urine retention
gustatory
sweating